Regional anesthesia for head and neck surgery declined rapidly after general anesthesia and tracheal intubation became available and accepted. Despite the decline in using regional anesthesia for head and neck surgery, in few other areas in the body can such small doses of local anesthetic provide such effective regional block. Likewise, one of the reasons head and neck block fell into disuse is that in no other body region can such small doses of local anesthetic produce systemic toxicity so easily. There are still circumstances in which head and neck block is useful, however. Many of them involve the diagnosis or treatment of pain syndromes. Also, many plastic surgical procedures on superficial structures can be managed easily with effective block of the nerves of the head and neck. One aspect of head and neck block that should not be considered optional for anesthesiologists is the development of expertise in airway anatomy and innervation. In some circumstances in an anesthetic practice, proper airway management, including airway blocks, can be life-saving.

Sensory innervation of the face is provided by the trigeminal nerve. Three branches of the trigeminal—ophthalmic, maxillary, mandibular—provide innervation, as illustrated in
Figure 18-1
. The cutaneous innervation of the posterior head and neck is from the cervical nerves. The dorsal ramus of the second cervical nerve ends in the greater occipital nerve, which provides cutaneous innervation to the larger portion of the posterior scalp (see
Fig. 18-1
). The greater occipital nerve is a continuation of the medial branch of the dorsal ramus of the second cervical nerve and ascends from the cervical vertebrae to the muscles of the neck in company with the occipital artery. The greater occipital nerve becomes subcutaneous in its course, with the occipital artery immediately lateral to the inion, slightly inferior to the superior nuchal line (
Fig. 18-2
). The ventral rami of cervical nerves II, III, and IV provide most of the cutaneous innervation to the anterior and lateral portions of the neck, with cervical nerve II providing innervation to the scalp through both the lesser occipital and the posterior auricular nerves (see
Fig. 18-1
). The superficial cervical plexus is formed as cervical nerves II, III, and IV leave the vertebral transverse processes and follow a course in which they become subcutaneous at the midpoint of the posterior border of the sternocleidomastoid muscle (see
Fig. 18-2
). At this point, the superficial cervical plexus can be easily blocked by infiltration.

Figure 18-1 Head and neck anatomy: innervation.

Figure 18-2 Head and neck anatomy: peripheral nerves.

The trigeminal nerve is a mixed motor and sensory nerve, although most of it involves sensory innervation. The only motor fibers are the branches that supply the muscles of mastication via the mandibular nerve. The trigeminal nerve is organized in the cranium within the trigeminal ganglion (gasserian or semilunar ganglion). From this ganglion, the ophthalmic nerve exits from the cranium via the superior orbital fissure, the maxillary nerve via the foramen rotundum, and the mandibular nerve via the foramen ovale (
Fig. 18-3
). After leaving these foramina, the maxillary and mandibular nerves follow courses that place them in the immediate proximity of the lateral pterygoid plate. The pterygoid plate is an important landmark for effective maxillary or mandibular block (
Fig. 18-4
). The terminal branches of the trigeminal nerve end in the supraorbital, infraorbital, and mental nerves. These nerves exit through bony foramina that are on a line perpendicular through the pupil, as illustrated in
Figure 18-5
.